Catholic Care Center, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 147 residents. The sample included 29 residents with Resident (R) 93 reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure staff provided appropriate and safe assistance with activities of daily living (ADL) to R93 during a transfer which resulted in bruises to both R93's arms. This deficient practice placed R93 at risk of decreased ADL ability, pain, and psychosocial distress. Findings included: - R93's Electronic Medical Record (EMR) documented diagnoses of repeated falls, hypertension (HTN-elevated blood pressure), blindness in one eye, and dementia (a progressive mental disorder characterized by failing memory and confusion). R93's Significant Change Minimum Data Set (MDS) dated 06/28/24 documented she had a Brief Interview for Mental Status (BIMS) score of 10 which indicated a moderately impaired cognition. R93 required substantial to maximal assistance of staff for bed-to-chair (or wheelchair) transfers. R93 had a history…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 147 residents. The sample included 29 residents with seven residents reviewed for treatment and services to prevent and/or heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 22's heels were offloaded either by boots or a pillow and further failed to ensure R13 was provided a pressure-reducing cushion for his wheelchair. This placed R22 and R13 at increased risk for pressure ulcer development and delayed healing. Findings Included: - R22's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics), diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 147 residents. The sample included 29 residents with two residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 52's physician-ordered supplemental oxygen supply was turned on. The facility failed to ensure R109's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) was stored appropriately when not in use. This placed R52 and R109 at risk of respiratory complications and possible infection. Findings included: - R52's Electronic Medical Record (EMR) documented diagnoses of respiratory failure (a condition where your blood does not have enough oxygen), dysphagia (swallowing difficulty), aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit), dementia (a progressive mental disorder characterized by failing memory and confusion), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 147 residents. The sample included 29 residents with three residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 80's access site for complications at least daily and document the arteriovenous (AV-a surgically created connection between an artery and a vein used for hemodialysis) fistula for the thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with a stethoscope that may occasionally also be palpated as a thrill) every day. This deficient practice placed R80 at risk of adverse outcomes and physical complications related to dialysis. Findings included: - R80's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of end-stage renal disease (ESRD-a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 147 residents. The sample included 29 residents with two residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 75's and R107 posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R75 and R107 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 147 residents. The sample included 29 residents with two reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record review, and observations, the facility failed to provide dementia-related behavioral services for Resident (R)30 to promote her highest practicable level of well-being. This deficient practice placed R30 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R30's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), history of seizures (violent involuntary series of contractions of a group of muscles), epilepsy (brain disorder characterized by repeated seizures), and insomnia (difficulty sleeping). R30's Significant Change Minimum Data Set (MDS) completed 10/30/24 noted a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. The MDS noted that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 147 residents. The sample included 29 residents with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were acknowledged and/or acted upon for Resident (R) 75. This deficient practice placed R75 at risk for unnecessary medication use and possible adverse side effects. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R75 received antianxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 147 residents. The sample included 29 residents with six reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to follow instructions related to medication monitoring when staff administered Resident (R)303's anti-hypertensive (class of medication used to treat high blood pressure) medications outside the physician-ordered parameters. This deficient practice placed R303 at increased risk for unnecessary medication and side effects. Findings included: - The Medical Diagnosis section within R303's Electronic Medical Records (EMR) included diagnoses of acute respiratory failure, atherosclerotic heart disease (reduced blood flow due to blockages in the arteries within the heart), atrial fibrillation (rapid, irregular heartbeat), hypertension (high blood pressure), and chronic kidney disease. R303's EMR revealed he was admitted on [DATE] and discharged on 11/15/24 to an acute care facility for emergency treatment. R303 did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 147 residents. The sample included 29 residents with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the as-needed (PRN) psychotropic (alters mood or thought) medication had a 14-day stop date or a specified duration with supporting physician documentation for Resident (R) 75's and R13's PRN psychotropic medications. This placed these residents at risk for unnecessary medication administration and possible adverse side effects. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 147 residents. The sample included 29 residents with Resident (R) 93 reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure collaboration of care between R93's hospice provider and the facility. This placed R93 at risk of inadequate end-of-life care. Findings included: - R93's Electronic Medical Record (EMR) documented diagnoses of repeated falls, hypertension (HTN-elevated blood pressure), blindness in one eye, and dementia (a progressive mental disorder characterized by failing memory and confusion). R93's Significant Change Minimum Data Set (MDS) dated 06/28/24 documented she had a Brief Interview for Mental Status (BIMS) score of 10 which indicated a moderately impaired cognition. R93 required substantial to maximal assistance of staff for bed-to-chair (or wheelchair) transfers. R93 had a history of one fall without injury and one fall with injury since her prior assessment. R93 was on hospice services. R93's Quarterly MDS dated 06/28/24 documented she had a BIMS score of 13 which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 89 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to promote dignity during the dining experience for residents in two of three dining rooms when staff scraped off soiled plates next to residents who were still eating and nursing staff administered eye drops and nasal spray medications in the dining room in front of other residents. The facility further failed to ensure a dignity cover for R21's urinary drainage bag. This deficient practice placed residents at risk for impaired dignity and embarrassment. Findings included: - On 02/22/23 at 09:02 AM, while several residents were still eating, observation revealed Certified Medication Aide (CMA) R wheeled the garbage cart between dining tables, scraping off soiled plates within one foot of seated residents still dining. On 02/22/23 at 12:40 PM, observation revealed Dietary Staff (DS) CC cleaned off tables with residents still sitting there. Continued observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 89 residents. The sample included 18 residents. Based on record review and interview, the facility failed to provide three sampled residents, Resident (R)13, R38 and R189 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, (CMS) Centers for Medicare and Medicare Services which placed them at risk to make uninformed decisions about their skilled care Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The facility failed to provide R13 the completed form 10055, which estimated the cost for the services to be able to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 89 residents. The sample included 18 residents with seven reviewed for accidents. Based on observation, interview, and record review the facility failed to review or revise the care plan to prevent further falls for Resident (R) 19 after three of her falls. This deficient practice placed R19 at risk for further falls and injury. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of severe dementia (group of thinking and social symptoms that interferes with daily functioning), unsteadiness on feet, muscle weakness, and chronic pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of zero, and short- and long-term memory problems with severely impaired decision making. The MDS documented R19 required extensive assistance of one staff for eating, hygiene, extensive assistance of two staff for bed mobility, transfers, walking, locomotion, toileting, dressing and total assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 89 residents. The sample included 18 residents with six residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing for one of the six reviewed for ADLs, Resident (R)33. This placed the resident at risk for poor personal hygiene and infection. Findings included: - R33's Electronic Medical Record (EMR) recorded diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), diabetes mellites (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and muscle weakness. R33's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R33 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognition impairment. The MDS recorded R33 required extensive assistance of one staff for most activities of daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 89 residents. The sample included 18 residents with seven reviewed for accidents. Based on observation, interview, and record review the facility failed to identify and implement meaningful, resident-centered interventions to prevent falls for Resident (R) 19 and failed to complete ongoing monitoring for fall related injuries after falls. This deficient practice placed R19 at risk for further falls or injury. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of severe dementia (group of thinking and social symptoms that interferes with daily functioning), unsteadiness on feet, muscle weakness, and chronic pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of zero, and short- and long-term memory problems with severely impaired decision making. The MDS documented R19 required extensive assistance of one staff for eating, hygiene, extensive assistance of two staff for bed mobility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 89 residents. The sample included 18 residents with one reviewed for pain. Based on observation, interview, and record review the facility failed to prevent a medication error when pain medications were not administered as ordered by the physician for Resident (R) 19. This deficient practice place R19 at risk to potentially receive harmful amounts of her pain medication. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of severe dementia (group of thinking and social symptoms that interferes with daily functioning) and chronic pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of zero, and short- and long-term memory problems with severely impaired decision making. The MDS documented R19 required extensive assistance of one staff for eating, hygiene, extensive assistance of two staff for bed mobility, transfers, walking, locomotion, toileting, dressing and total assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 89 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to ensure the medication for Resident (R) 5 was labeled in accordance with currently accepted professional standards. This deficient practice placed R5 at risk for medication errors. Findings included: - On 02/22/23 at 08:51 AM, observation revealed Certified Medication Aide (CMA) S applied a Salon Pas (pain medication) patch, 3.1/6%, to each of R5's knees. The Physician Order, dated 04/02/21, directed staff to apply the Salon Pas patch to R5's mid and lower back for pain daily. On 02/22/23 at 01:06 PM, Licensed Nurse (LN) G verified the physician's order directed staff to administer R5's Salon Pas patches to his mid and lower back. On 02/22/23 at 01:14 PM, CMA S showed R5's Salon Pas medication box had a handwritten message to apply to both legs. The pharmacy label was still on the box with the instruction to apply to mid and lower back. On 02/22/23 at 01:15 PM, Administrative Nurse E verified the physician order directed staff to apply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 89 residents. The sample included 18 residents with one reviewed for urinary catheter (tube inserted into the bladder to drain urine) or urinary tract infection (UTI). Based on observation, record review and interview the facility staff failed to change gloves when providing Resident (R) 18 incontinent cares and continued to provide care with the same soiled gloves. This placed the resident at risk for infection. Findings included: - R18's Electronic Medical Record documented R18 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory, confusion), and muscle weakness. R18's Quarterly Minimum Data Set, dated 01/20/23, documented R18 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R18 required extensive staff assistance with transfers, locomotion off unit, bed mobility, toiler use and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility census totaled 135 residents. The facility had one main kitchen with five satellite kitchens. Based on observation, interview, and record review the facility failed to ensure sanitary use of gloves while preparing and serving food to residents in one of five satellite kitchens on the 200 Hall. Twenty-six residents resided on 200 Hall. Findings included: - Observation on 06/22/21 at 11:27 AM revealed Dietary Aide Q in the 200 Hall satellite kitchen served lunch, wore gloves, and used utensils to serve except when he unwrapped the baked potatoes and touched the potatoes with the same gloves he used to open cabinets, touch utensils, retrieve plates, papers, touch plates, and push up his glasses. Interview with Dietary Aide Q on 06/22/21 at 11:47 AM revealed he used utensils for handling food and indicated he wore gloves, so it was ok. Interview with Dietary Manager R on 06/22/21 at 02:42 PM verified Dietary Aide Q only worked on the 200 Hall and if staff used gloves, they should remove them if they have touched something other than the food, because we use utensils for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 135 residents with 27 residents included in the sample and two residents reviewed for hospitalizations. Based on interview and record review the facility failed to provide Resident (R) 274 and his representative written notice of the reason for the transfer/discharge to the hospital. Findings included: - Review of the Physician's Orders in the Electronic Medical Record (EMR) dated 06/11/21 revealed R274 had diagnoses of: cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area, also known as a stroke) and epilepsy (brain disorder characterized by repeated seizures). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition with seizures noted. Review of the Quarterly MDS dated 04/07/21 revealed a BIMS of 11, indicating moderately impaired cognition with seizures noted. Review of the ADL Care Area Assessment (CAA) dated 01/22/21 revealed R 274 was at another community for short…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 135 residents with 27 residents included in the sample and two residents reviewed for hospitalizations. Based on interview and record review the facility failed to provide Resident (R) 274 and his representative with a bed-hold policy upon transfer to the hospital. Findings included: - Review of the Physician's Orders in the Electronic Medical Record (EMR) dated 06/11/21 revealed R 274 had diagnoses of: cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area, also known as a stroke) and epilepsy (brain disorder characterized by repeated seizures). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition with seizures noted. Review of the Quarterly MDS dated 04/07/21 revealed a BIMS of 11, indicating moderately impaired cognition with seizures noted. Review of the ADL Care Area Assessment (CAA) dated 01/22/21 revealed R 274 was at another community for short term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility census totaled 135 residents with 27 residents in the sample. Based on observation, interview, and record review the facility failed to update Resident (R)98's care plan with care and maintenance of the Bilevel Positive Airway Pressure (BIPAP- machine that uses pressure to push air into the lungs, opening the lungs and improving the level of oxygen in the blood and decreasing the carbon dioxide) equipment and supplies. Findings included: - R98's pertinent diagnoses from the Physician's Orders Diagnosis in the Electronic Medical Record (EMR) dated 05/05/21 revealed chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 01/28/21 Significant Change Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition and use of a BIPAP. Review of the 01/28/21 Activities of Daily Living [ADLs] Care Area Assessment (CAA) revealed R98 was recently hospitalized for acute (quick onset) chronic (long-term) hypercapnia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 135 residents with 27 included in the sample. Based on observation, interview, and record review the facility failed to ensure one of two residents reviewed for ADLs (Activities for Daily Living) received assistance from staff for grooming as evidenced by Resident (R) 103 was unshaven and had fingernails that needed to be trimmed. Findings included: - Review of the Physician Progress Note dated 06/02/21 for R103 revealed the following diagnosis: Dementia without behaviors (progressive mental disorder characterized by failing memory, confusion). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score three which indicated severely impaired cognition. R103 required limited assistance with personal hygiene and dressing, and activity did not occur for bathing. Review of the Quarterly MDS dated 05/26/21 revealed a BIMS of three which indicated severely impaired cognition. R103 required extensive assistance with personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility census totaled 135 residents with 27 residents in the sample with one resident reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure that Resident (R)98's Bilevel Positive Airway Pressure (BIPAP- machine that uses pressure to push air into the lungs, opening the lungs and improving the level of oxygen in the blood and decreasing the carbon dioxide) was maintained and stored in a sanitary manner. Findings included: - R98's pertinent diagnoses from the Physician's Orders Diagnosis in the Electronic Medical Record (EMR) dated 05/05/21 revealed chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 01/28/21 Significant Change Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition and use of a BIPAP. Review of the 01/28/21 Activities of Daily Living [ADLs] Care Area Assessment (CAA) revealed R98 was recently hospitalized for acute (quick onset)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility census totaled 135 residents, with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to complete physician orders in response to the monthly Medication Regimen Reviews (MRR) from the consultant pharmacist for Resident (R) 60 for the addition of an end date for the resident's PRN psychotropic medication and correction to the antipsychotic medication diagnosis. Findings included: - Review of R60's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 05/03/21 documented Major Depressive Disorder (MDD) major mood disorder), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and muscle spasms. Review of the 05/08/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, indicating moderately impaired cognition with no behaviors. R60 received antipsychotic medications on a routine bases only with no as needed (PRN) doses received. R60's Psychotropic Drug Use Care Area…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility census totaled 135 residents, with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to monitor Resident (R)60's effectiveness of Lasix (diuretic, medication used to promote the excretion of fluids) as ordered by the physician. Findings included: - Review of R60's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 05/03/21 documented hypertension (elevated blood pressure) and chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). Review of the 05/08/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, indicating moderately impaired cognition. R60 weighed 193 pounds and received diuretics three of the seven day look back period. R60's Cognitive Loss/ Dementia Care Area Assessment (CAA) dated 05/08/21 documented R60 scored seven on the BIMS, indicating severely impaired cognition. The 05/03/21 Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility census totaled 135 residents, with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to initiate doctor's orders to limit the time frame of an as needed (PRN) psychotropic medication and obtain an appropriate indication for use of an antipsychotic medication for Resident (R) 60. Findings included: - Review of R60's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 05/03/21 documented Major Depressive Disorder (MDD major mood disorder), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and muscle spasms. Review of the 05/08/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, indicating moderately impaired cognition with no behaviors. R60 received antipsychotic medications on a routine bases only with no PRN doses received. R60's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/08/21 documented R60 had the diagnosis of depression for which she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.